Healthcare Provider Details

I. General information

NPI: 1225336159
Provider Name (Legal Business Name): MARY AC YETTA MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/01/2011
Last Update Date: 03/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2021 DUBLIN ST
NEW ORLEANS LA
70118-2920
US

IV. Provider business mailing address

2021 DUBLIN ST
NEW ORLEANS LA
70118-2920
US

V. Phone/Fax

Practice location:
  • Phone: 504-756-4554
  • Fax:
Mailing address:
  • Phone: 504-756-4554
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number4503
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: